Unlike illegal drugs, prescription drugs come from known manufacturers, pass through known distributors to known pharmacies where they are dispensed as prescribed by known prescribers to patients. So how then are these drugs ending up being so widely abused?

There are several ways:

Prescribers may be prescribing too much to individual patients ("Injudicious prescribing" or outright drug-dealing)

Patients may be seeing many prescribers ("Doctor-Shopping")

Drug dealers may hire "mules" (fake patients) to obtain drugs

Drugs may be stolen from patients for whom they are legitimately and appropriately prescribed, often by "caregivers" and family.

Prescription Monitoring Programs are State-funded online databases that are designed to catch over-prescription and doctor shopping by placing ALL controlled substance prescriptions into a readily visible web-site that can be accessed by prescribers, pharmacists and law enforcement. This means that if "Patient X" is doctor-shopping and has received ten prescriptions for Oxycontin from different doctors over the last two months, the eleventh doctor can learn this simply by looking the patient up on the database. In theory, this should work perfectly... IF every prescriber actually checks the PMP BEFORE writing a controlled substance prescription. And that is the problem... they don't always check. In fact, many physicians still don't have accounts on the State PMP and therefore cannot look patients up. All that is about to change in a big way here in New Mexico.

New Rules From the New Mexico Medical Board

Starting August 10, 2012, all New Mexico physicians are required by law to register with and most important, to actually use the New Mexico State PMP. Specifically this means that every one of us is REQUIRED to perform a PMP search on EVERY new patient to whom we issue a controlled substance prescription. This rule should , at least in theory, bring "doctor shopping" to a halt by exposing patients engaged in the practice.

Will it work?

I think that it will work. It will make it virtually impossible to doctor-shop and it will expose rogue prescribers. That is all very, very good, but there may be troubling consequences as well. They include several issues:

Catching prescription drug addicts is not the same thing as treating them.

Past experiences with attempts to prevent prescription drug abuse, for example by making Oxy-contin harder to crush or chew (and therefore to abuse) have worked well for the specific drug in question, but unfortunately there is substantial evidence that addicts then switch to other opiate drugs including heroin. While this ensures that health care workers are no longer unwitting participants in drug addiction, it may actually bring much greater harm to the addict and to society since, of course, heroin is a totally illegal substance that cannot be "regulated" even though it is outlawed. To put it more bluntly, drug addiction is a social and medical problem that ultimately requires more than just regulation. Law enforcement is a necessary but not a sufficient tool. Drug addicts are also human beings and they need treatment as well as consequences.

The PMP makes physicians participants, at least to a limited degree, in law enforcement. That is a role that many of us are uncomfortable with since it can place us in an adversarial relationship with our patients, people to whom we have a duty to do no harm. While I think that we are all smart enough to understand that reporting a potentially drug-addicted patient to the PMP may not inflict harm upon that patient and may in fact bring them help, the process can be pretty ugly and frankly, it rarely "feels" therapeutic. The truth is that maybe we physicians need to "grow up" a bit and face reality. Look again at the graph above. Reality is pretty terrible.

Government oversight of the practice of medicine scares some physicians and could cause them to become so reluctant to prescribe controlled substances that their patients suffer from under-treatment. The reality is that it is ALL about good record keeping. The New Mexico Medical Board has already issued a clear statement in this regard.

Bariatric Medicine, Non-Narcotic Controlled Substances and the PMP

So far I have been writing about prescription pain-killers, drugs like Vicodin, Morphine, Oxycodone and so on. But the PMP covers ALL controlled substances including those that are not narcotics and including drugs like phentermine, phendimetrazine and diethylpropion. In other words, nearly all of the medications that we use in bariatric medicine must be reported to the PMP. This raises several issues that I want to address.

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